Postpartum hospital stay debate turns to home care
Postpartum hospital stay debate turns to home care
Someone in the postpartum hospital stay debate finally stated the obvious in the national media. To paraphrase a political strategist’s slogan from the Clinton presidential campaign, "It’s about home care, stupid."
Current scientific knowledge and good judgment suggest services received at home or in the clinic during the first three to four days are the crucial issue not length of stay, says Paula Braveman, MD, MPH, an associate professor of family and community medicine and epidemiology and biostatistics at the University of California at San Francisco. Braveman’s commentary about the postpartum hospital stay issue was published in the July 23 Journal of the American Medical Association (JAMA).1 (For results of a study on prenatal home visits, see p. 131.)
Legislation passed by Congress and signed by President Clinton requires insurance companies to cover a minimum 48-hour hospital stay for newborns. The legislation was in response to safety concerns about "drive-through deliveries," a cost-cutting measure by insurers and hospitals that discharged routine vaginal-birth newborns and their mothers within a day of delivery.
"I don’t think the 48-hour rule is beneficial to families," says Carolyn A. Mullins, RN, MS, A-CCC, regional vice president for Pediatric Services of America Inc. (PSAI) in Charlotte, NC. "It’s a real shame families have lost out. Even though it sounds good and people jumped on the bandwagon, they don’t understand the true issue here."
When the 48-hour stay became the rule, families from one of PSAI’s large contracts lost their postpartum home visit benefit. "It’s a lot more beneficial to be able to help [mothers] in their homes. Then we can be there to work through all these issues in the quiet and the privacy of their home rather than the second day in the hospital."
Mullins says she agrees that if there’s no home care available, then the second day of hospital stay would probably be better for the mother. "But the responses we got from our families is that they were always so happy to have had that time at home with someone one-on-one."
PSAI’s mother-baby visits usually averaged about two hours. PSAI nurses first would meet the mothers in the hospital to get general information such as where they lived and directions to the home. Teaching also began then.
"We generally saw them 48 to 72 hours after discharge," Mullins explains. "Usually we’d see them the day of discharge. Then we would make a phone call and do one home visit, unless we saw that they needed more. We took a lot of time to do basic teaching or whatever that family needed."
A tale of two studies
In the JAMA commentary, Braveman and colleagues interpret the implications of two large studies published in the current JAMA that reach seemingly contradictory conclusions about the safety of short postpartum hospital stays.
One study, from the University of Washington finds that newborns who are discharged from the hospital within 30 hours of birth are at an increased risk for rehospitalization during the first month of life, especially during the first week. Another study, from the University of Wisconsin, finds that early postpartum discharge has little effect on the risk of rehospitalizations due to feeding problems in normal, healthy newborns born to healthy moms.
The studies, which are the largest yet to look at early discharge, may not actually be discrepant, according to Braveman, because the Wisconsin study lacked sufficient statistical power to support its conclusions. However, Braveman points out neither study reveals the optimal length of postpartum stay for well newborns and mothers.
In the case of early discharge, science does not and probably cannot supply airtight evidence that longer stays are more effective compared with other approaches, according to the commentary. However, when considering what is currently known about early postpartum and neonatal health, Braveman says good judgment and the weight of existing information suggest a range of options to ensure timely assessment and intervention during the early postpartum period.
"Good judgment says that it is not acceptable to await conclusive evidence on the most efficient approach to postpartum hospital stays before ensuring that every mother and newborn receives some kind of health-promoting care," Braveman says. "I think home care is the whole answer to this," concludes Mullins.
Reference
1. Braveman P, Kessel K, Egerter S, et al. Early Discharge and evidence-based practice: Good science and good judgment. JAMA 1997; 278:334-336.
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